otites treatment (1).pdf

Acute otitis media in children: Treatment Authors: Stephen I Pelton, MD, Paula Tähtinen, MD, PhD Section Editors: Morven S Edwards, MD, Glenn C Isaacson, MD, FAAP Deputy Editor: Diane Blake, MD Contributor Disclosures All topics are updated as new evidence becomes available and our peer review pro...

Acute otitis media in children: Treatment Authors: Stephen I Pelton, MD, Paula Tähtinen, MD, PhD Section Editors: Morven S Edwards, MD, Glenn C Isaacson, MD, FAAP Deputy Editor: Diane Blake, MD Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2024. | This topic last updated: Jan 16, 2024. INTRODUCTION Acute otitis media (AOM), also called purulent otitis media and suppurative otitis media, is a common problem in children and accounts for a large proportion of pediatric antibiotic use. The treatment of uncomplicated AOM will be reviewed here. The epidemiology, pathogenesis, diagnosis, complications, and prevention of AOM are discussed separately, as is otitis media with effusion (serous otitis media). (See "Acute otitis media in children: Epidemiology, microbiology, and complications".) (See "Acute otitis media in children: Clinical manifestations and diagnosis".) (See "Acute otitis media in children: Prevention of recurrence".) (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis".) (See "Otitis media with effusion (serous otitis media) in children: Management".) DIAGNOSIS OF AOM The clinical diagnosis of AOM requires one or more of the following [1,2] (see "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Diagnosis'): Bulging of the tympanic membrane ( picture 1) – Children with severe/marked bulging of the tympanic membrane appear to benefit most  from antibiotic therapy. Bulging of the tympanic membrane is more likely to be associated with a bacterial pathogen in the middle ear [4,5]. Signs of acute inflammation (eg, marked erythema of the tympanic membrane and fever or ear pain) and middle ear effusion – Although signs of acute inflammation and middle ear effusion without bulging may represent early AOM, it is challenging for young children to localize pain to the ear [1,2]. Perforation of the tympanic membrane with acute purulent otorrhea if acute otitis externa has been excluded. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Diagnosis'.) Accurate diagnosis ensures appropriate treatment for children with AOM, who require antibiotic therapy, and avoidance of antibiotics in children with otitis media with effusion, in whom antibiotics are unnecessary. CLINICAL COURSE WITHOUT ANTIBIOTICS The acute symptoms and signs of AOM often resolve within three days whether or not children are treated with antibiotics [6-8]. Antibiotic administration has been demonstrated to slightly hasten the resolution of pain. In a meta-analysis of seven randomized trials comparing antibiotics with placebo in 2320 children with AOM, 16 percent of those who did not receive antibiotics continued to have pain at two to three days (as compared with 11 percent of children who received antibiotic therapy). In a separate meta-analysis of randomized and observational studies in 1409 children who did not receive antibiotics, ear pain resolved within three days in 50 percent and within seven to eight days in 90 percent. (See 'Antibiotic therapy versus observation' below.) Middle ear effusion associated with AOM usually resolves spontaneously within several weeks, often by four to six weeks ( figure 1) [10-13]. The clinical features, complications, and management of persistent middle ear effusion are discussed separately. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Otitis media with effusion (serous otitis media) in children: Management".) MANAGEMENT OF PAIN Pain management is a mainstay of the treatment of AOM in children [1,14]. We provide treatment to reduce ear pain in children whether or not they are treated with antibiotics. Pain is a common feature of AOM and may be severe. Oral and topical analgesics – We suggest oral ibuprofen or acetaminophen rather than other interventions for treatment of ear pain in children with AOM. With severe pain unresponsive to either ibuprofen or acetaminophen alone, a combination of both ibuprofen and acetaminophen may be needed. Although topical anesthetics applied to the tympanic membrane appear to be effective in relieving ear pain [15,16], they are not licensed for this indication in the United States. In addition, the US Food and Drug Administration added a boxed warning to viscous lidocaine after severe adverse events were reported in infants and children (primarily when it was used for teething or stomatitis). Topical procaine or lidocaine preparations should be used with caution in children and avoided in those with tympanic membrane perforation. Topical benzocaine is avoided in children